RUN FOR MILES KEEPING HIS MEMORY ALIVE 3RD ANNUAL 5K RUN/WALK FUN RUN (IN MEMORY OF TOMMY BOURGEOIS) BERWICK HIGH SCHOOL APRIL 25, 2015 WWW.MILESLINERFOUNDATION.COM ENTRY FORM (mail to): The Miles Liner Foundation, Inc. 513 Watson Street Berwick, LA 70342 Name of Participant: _______________________________________________________ *Each Participant Must Complete a Form. Age: ______________Phone #_________________________________________________ *If you are making one check for multiple participants, please include all forms with the check. Address: ____________________________________________________________________ City & State: ____________________________________Email:______________________________________________ REGISTER BY MARCH 27TH AND All Participants WILL BE ENTERED INTO EARLY BIRD CASH DRAWINGS!! (Drawings will be drawn prior to race start) Shirts and bags are only guaranteed if entry form received by April 15th. Registration after April 15th or the day of the event, an additional $5 will be assessed for the race chosen. Check One REGISTRATION FEE: _____1 MILE FUN RUN…….$15 (Check One) _____5K WALK/RUN……….$20 * Only 5K participants eligible for prize drawings. *Must be present to win. Sign in/Race Day Registration: 7 to 7:45 am Race Time: 1 mile fun run – 8:00 am 5K run/walk – 8:30 am RAIN OR SHINE: No make-up date or refunds AWARDS: All fun run entries receive a medal. Trophies go to 1st,2nd, 3rd overall male and female. Medals go to 1st,2nd and 3rd in each age group. Youth Small Y Medium Y Large Adult Small Adult Medium Adult Large Adult X Large Adult 2X Large (add $5) Adult 3X Large(add $5) Amount Paid: In completing this entry I declare that I, or anyone that I am paying for, will not compete in the event unless medically fit to do so and that, in any event, we will compete at my/our own risk. I accept that The Miles Liner Foundation, Inc. will not be liable for any loss, damage, action, claim, costs or expenses which may arise in consequence of my/our participation of the event. I/We understand that entry fees are non-refundable. I also hereby give my permission to pass my/our details to my chosen charity and to use my/our name, quotes, video footage, and photographic likeness for marketing and promotional purposes. I also agree to the full Terms and Conditions as displayed on the event website. / PRINT NAME SIGNATURE (PARENT OR GUARDIAN IF UNDER 18 /2015 DATE